Premise: Lemmietta McNeilly opened the forum by presenting the results of a survey of Health Care Conference/Business Institute 2013 pre-registrants. The survey's purpose was to better understand professional challenges in health care and to identify ways to better serve ASHA members. Then Patty Prelock took the floor to field questions.

Member 1: As far as the bundled payments and the changes in reimbursement models: Historically, weren't some of those payment models used in the past, and then we got away from them and now they're coming back? Can you talk about that a little bit?

Prelock: Great question. She's asking, didn't we used to have sort of bundled payments or episodic care, and then we left that framework and went fee-for-service. Paul, I don't know what your experience has been in the rehab hospital. I know for us in Vermont—we've always done things a little differently from everybody else—but I think there were frameworks like that.

Paul Rao: For example, in rehab we went from having a per diem to a prospective payment for the whole stay. SNFs [skilled nursing facilities] are still [per diem]. ... CMS [The Center for Medicare and Medicaid Services] has moved to bundled payments lately with acute care and DRGs [diagnosis-related groups].

Member 2: In Colorado, apparently Medicare is no longer going to pay for speech therapists to do cognitive evals or treatment, and I'm from a trauma [level] 2 hospital where we get head injuries all the time. So, is this a national thing, or just my region? And have other people heard about that?

Prelock: Janet, did you have a comment?

Janet Brown: Medicare is a little unusual because there is a code and there's a national Medicare policy supporting all of that. Would you please contact ASHA, though, because our reimbursement unit will contact the Medicare administrative contractor. There's a national Medicare policy, but regionally there are Medicare administrative contractors. They can have their own variations on that, but that's something—if that's the case and that's their policy—that ASHA would strongly try to advocate, write a letter, and get that changed.

Prelock: Didn't we do a letter to Colorado recently? I know I've done so many letters, not on that topic.

Member 3: Is Medicare reimbursing someone else to do that service?

Member 2: I don't know that.

Theresa Rogers: If you'll give us your contact information, we will put our reimbursement unit on that. And we'd be happy to contact the agency in your state to get some additional information.

Prelock: Thank you for bringing that to our attention.

Member 4: We were just told to be more careful with the coding, because their number of diagnoses that are covered under the cognitive eval have gone down—from what we were told. We were just told to be very careful about what diagnosis you put for a cognitive eval and cognitive treatment. So maybe that's it, it's just that the number of diagnoses have gone down, but I don't know.

Member 2: Can you give an example of how you'd be "careful" about that? You can't lie, you've got to—

Member 4: Right, right. Meaning, something that may have been covered prior to, won't be covered now. Not being careful in terms of, "don't put the diagnosis." But maybe last year, a certain diagnosis was covered but now it's not. So we were just told to double-check that page that says what the diagnosis code can be for evals, before we just do what we've been doing.

Prelock: I think [this] brings an important piece to the discussion. So, as Theresa said, we're going to take that back and make sure that we follow up. And as Janet said, these are the kinds of issues you should bring forward, because then we will send a letter. We will investigate it and send a letter in support of services.

Rao: For the past year we've been working [on this] with ASHA. Aetna, for example, has a benefit for cognitive rehab—they have codes—but they're just not paying. So we've written, we've appealed, and so I think that's something you have to stay on. You have to get to the appeal. But the consumers are saying, "Look, it's here, it's in my benefit package." ... [The insurer assumes] most of what you're doing under stroke and TBI is language, and you're not really doing cognitive and [they're] not going to pay for it. So, it's a rationing. And somehow we need to get to the next level. It's already in the Aetna package.

Member 5: When I coded something with the diagnosis the doctor had given as post-concussion syndrome, then they came back and said, "No, we only cover stroke and TBI." So if it's not directly a traumatic brain injury code, they were trying to say that post-concussion syndrome was not included.

Member 6: One of the issues that I don't know if anyone else has been experiencing is I feel like a lot of my patients have been going M.I.A. recently. I think a lot of it has to do with third-party payers, where you call, they say ... 45 visits a year. In your mind, you're good to go. So, by the time the billing cycle goes through they've seen you for three sessions. All of a sudden, "No, we're not going to pay for that diagnosis." You had no idea when you started your treatment plan. I look at it from a, number one, a liability standpoint—OK, now we're just leaving these people. But I also look at it as, since we are going to know the functional outcomes, I feel like with Medicare when we report the G-codes, so much information is lost. Let's say a patient got worse—where do I tell them this? It got worse because they're still smoking two packs a day. ... I really have a concern about that. I understand we need functional outcomes ... I absolutely think we should do more value-based reimbursement. More value to our services and our care. But at the same token, you know, you look at readmission to hospitals. As a provider, you can educate your staff, you can educate your patients. But it doesn't matter if you still have somebody who came in with ... the doctor says they're obese, smoke, drink, et cetera, and we could educate them until the cows come home. If they go home and do the same thing. I just feel like as a profession, we're having to take on so much of that. I understand that we do need to take on accountability, but ...

Prelock: ... How do you account for all the other pieces?

Member 6: Absolutely! I feel like I'm at a loss. I don't feel like there's a good support system. ... I can tell you I have sent e-mails to Florida's board, FLASHA. I don't get responses. So I'm thinking, am I the only one who's having patients that are going M.I.A. because things just aren't getting covered? Is it a regional thing, is it a national thing? I don't know.

Prelock: And you are ...

Member 6: From Florida.

Prelock: Are other people having a similar experience?

Member 7: I'd like to piggyback on her [question], because I'm from Florida too. My issue is FLASHA, our state agency ... we're pretty much broke. We can't afford a lobbyist at Tallahassee, and that's how you get things done in Florida. You have to have your lobbyist up there, you have to have people that know what they're doing. What we need is money to pay for a lobbyist.

Member 6: In Florida—I don't know if it's just us, or if other states are going to follow this trend—but even for our CEUs ... even though here they're covered, anything that's business [institute]-related, it doesn't apply.

Prelock: It sounds like you need support. We do have an ASHA liaison for Florida. We will get that looked at.

Member 6: I told the girl I registered with, I'm at the point—almost—you know, do I continue [in] this field? (other attendees express dismay)

Member 6: I feel like a lot of the reimbursement [sessions] have really helped, but I don't know if it's just here, is it nationally? This is ludicrous to me ... "OK, we'll pay for your therapy, but we don't authorize evals."

Prelock: That's strange.

Member 6: You know, "We won't pay for any speech unless it's due to a trauma or congenital..."

Prelock: Right.

Member 6: We're saying we need to add value to our profession, but when our hands are tied ... we're also saying—by not treating these people, by not making them pay out of pocket—"You're OK, it's not life or death." What is the message that we're sending, and what does that mean for us in the future?

Prelock: I think you're raising some big questions. Were you going to say something?

Member 8: I was just going to say there are a lot of people who will pay out of pocket when their insurance really does not cover a lot of things. I think you have to learn how to work and navigate the delta of health care. (laughter) There's twists and turns. The pay cycle is hard, because it is a month later and they may have discharged. Especially in voice, depending on how effective you are.

Prelock: I think we have some support that can help you, but I did want to get back to one thing that you said. That is, the patient you're trying to educate, and then they're not following through, and then that you feel like you're being dinged because we're looking at functional outcome. I think if you look more at the International Classification of Function, the ICF looks at what are the impairments, and activities and participation, but it also looks at environmental factors and personal factors. I think if we use that framework and model, that will help us demonstrate that here's the elements that you're contributing—and also when talking to our patients about how they can be fully participatory. But to truly be patient-centered, you have to give them the information but they're going to make their own decisions. I think having that system and that framework to document that will be really important. Physicians ... have the same frustrations. And that's why they're looking at creating medical homes, and primary care that has prevention and wellness. So you see a young person who's obese, and then at 30 you see that the behaviors are not improving, and at 50 they have a stroke. So from 18–50 what did we do to help avoid that? And is there a way that we can participate in that? Those are some of the real hard conversations in health care right now. And whether you pay for your health care or not does seem to impact some of those people. But we want everyone to have access. So you're asking a really important question. I think it's important that we recognize what our value added is, but if we look at the ICF framework we can see [the] other components and people recognize that. And how can we document that, and how can we change that environment for that individual if it's possible?

Member 9: I work in a skilled nursing facility—actually I'm a supervisor for a number of skilled nursing facilities—and there are two things I wanted to mention. The desire not to have a resident go back to the hospital within 30 days is having some really negative effects on skilled nursing. The physicians will do anything not to send that resident back out, because the nursing home wants them. And the hospital says, "I'm not going to send you people if you're sending them back to us," and of course the nursing home needs the business, so who ends up being at the front lines of all that a lot of times is the speech pathologist. Because of course when someone has a serious decline, guess what goes? Eating, which everyone cares about. ... There was a gentleman who had gone from eating regular food and being verbal to nonverbal, and was absolutely unsafe to swallow. But they kept him NPO [nil per os] five days. I couldn't believe it. I was astounded! But I refused to let them feed him, because really, he was overtly aspirating everything. So when this [patient's] lungs are filled with mashed potatoes, and then the family's going to sue me—as well they should. It's a very difficult situation, that's one thing. And I don't think that was ever the intent of that law, or that goal, but this is what's happening. The other thing—just an aside, and I don't know if ASHA can do anything about it—as I said, I work in a number of skilled nursing facilities. They all have different color codes. It's red for DNR [do not resuscitate] here, it's green for DNR there, it's yellow ... I think there should be some sort of standardized [system]. Because there are a number of us going to multiple facilities. I see the ophthalmologist, I see the podiatrist, I see the nurse practitioners, I see all of us going in and out of these regional facilities. Who can keep track of all this stuff, realistically? So those are my two things.

Prelock: Two excellent, excellent points. I know in our own ... trauma [level] 1 center and the SNFs in our area, they're struggling with not wanting to send them back, because then they end up ... with this back-and-forth thing. But I think having a speech pathologist have a dialogue with the physician and being a part of that team to say, here are the issues, and what if that family has not had a discussion about, what is the long-term care plan for this patient? And what is the expectation for this patient? We need to do a better job; hospitals working with nursing homes are struggling with that communication. But the standardized coding, that's a great—I don't know if there's anything we can do about it, but that's really good feedback.

Brown: This is the way of the world; it's about quality measures. So if a good quality measure is readmission to the hospital, that's what drives everything. As reports of patients suffering or families complaining, and quality is actually going down because of a particular measure, there'll be a readjustment. There'll be additional measures to make sure the patients and the SNFs aren't experiencing that situation. So I think quality measurement is definitely the way things are moving forward. It's just to counterbalance ones that are producing unwanted results. There will be additional ones. But this feedback is what CMS and other agencies need to hear to prevent patients from suffering from what was intended to be a quality measure.

For follow-up questions related to this discussion or to reimbursement in general, contact reimbursement@asha.org.